Soc.Sec#_____________________________Birthday:___________________Martial Status:________
Employer Name:_____________________________________Employment Start Date:_____________
Local Number:_______________________________________Effective Date on Plan:______________
Dependents:________________________________________Birthday:_________________________
________________________________________Birthday:_________________________
If you have additional dependents, list their name(s) and birthday (s) on the back of this form.
Pursuant to the confirmation election of my local union, my employer will contribute an amount as specified in the local's collective bargaining agreement on my behalf to the WSCFF Premium Reimbursement Plan.
